Background: Transvaginal mid-urethral synthetic mesh placement hasrevolutionized treatment of stress-urinary incontinence (SUI). This technique has been applied for correction of vaginal compartment defects. We report our experience of 65 consecutive cases using the Prolift (Gynecare) extraperitoneal sacrocolpopexy (EPS) mesh.
Methods: Trocar-guided sutureless transobturator EPS was performed in 65 patients. The patients ranged from 39yr to 85yr (65 yr average). Twenty-one anterior, nineteen posterior, and twenty-five combined repairs were performed. A concurrent transobturator mid-urethral sling was placed in 78.5% (51/65) of cases. An anterior EPS was performed for defects Grade III or higher. A posterior EPS was performed for defects Grade II or higher. In ten cases there was documented Grade II or greater uterine prolapse, none requiring simultaneous vaginal hysterectomy.
Results: Overall operative time averaged 67 min with a 70 cc estimated blood loss. Length of stay in hospital averaged 1.4 days and the Foley catheter remained in place an average of 2.5 days. Operative times increased from 47 min for a single compartment defect repair, to 59 min for a single compartment and SUIrepair, to 94 min for a combination repair with mid urethral sling. No intraoperative complications were noted in the posterior repair group. Two (4.3%) anterior EPScases a incidental cystotomy was repaired primarily. In one anterior EPS, cystoscopy revealed a trocar-sheath bladder base perforation. Due to the close proximity to the ureteric orifice and a peri-orifice hematoma a precautionary ureteral stent was placed without sequela.
Twenty anterior EPS (43.5%) patients went home at discharge with a Foley catheter. At two weeks no patient had an indwelling catheter or retention. Follow-up out to 12 months indicates no instances of mesh erosion. Three cases (4.6%) of recurrent prolapse have been observed, one Grade III cystocele following posterior EPS, one Grade III enterocele following combined EPS, and one recurrent uterine prolapse, Grade III following combined EPS.
Conclusions: Trocar-guided sutureless transobturator anterior and posterior EPS is a well-tolerated, efficient option for repair of vaginal herniation defects and uterine prolapse. It maybe safely done in combination with a mid-urethral sling. Transobturator trocar placement is in close proximity to the ureteral orifices. Confirmatory cystoscopy following trocar passage is an appropriate complement to ensure bladder and ureteral integrity. As this is a recent innovation, long term studies are required in order to evaluate the efficacy, safety, and patient acceptance of this novel approach to pelvic organ prolapse.